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  • Form Hs10094 Authorization For Release Of Health Records.doc

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AUTHORIZATION FOR RELEASE, USE AND DISCLOSURE OF HEALTH RECORDS PHYSICIANS REGIONAL HEALTHCARE SYSTEM Pine Ridge Collier Tel. (239) 348-4020 Tel. (239) 354-6045 Patient s Name: Date of Birth: Address:.

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The name of the individual or the name of the person authorized to make the requested disclosure. The name or other identification of the recipient of the information.

The Health Insurance Portability and Accountability Act of 1996 was put in place to help ensure privacy and yet ease of access to your medical records. A HIPAA Authorization Form is a document that allows a medical provider to share specific health information with another person or group.

If you do decide to obtain consent, you have complete discretion to design a process that best suits your needs. By contrast, the Privacy Rule requires an "authorization" for uses and disclosure of protected health information not otherwise allowed by the rule.

A HIPAA authorization form, also known as a HIPAA release form, is a document that individual signs for their health provider before the entity may use or disclose their protected health information (PHI).

Authorization for release of information is obtained when Protected Health Information of an individual is to be released or shared between organizations or with others outside the organization.

The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service. The purpose of the requested use and disclosure.

A HIPAA-compliant HIPAA release form must, at the very least, contain the following information: A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed.

A HIPAA patient authorization form is an agreement between a patient and healthcare provider. A signed form gives your organization permission to use the patient's health information or disclose it to another person or entity, depending on their wishes.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232